ANTIBIOTICS AND ANTIMICROBIALS –

Policy 4.1.11
ORTHOPAEDIC SURGERY – RECOMMENDATIONS
ANTIBIOTICS & Protocol 4
FOR PRE-OPERATIVE ANTIBIOTIC PROPHYLAXIS
ANTIMICROBIALS
PROTOCOL

BACKGROUND
Surgical Site Infection (SSI) is a potentially preventable major source of postoperative
morbidity. Standardised administration of prophylactic antibiotics decreases the rate of SSI
in Elective Orthopaedic Arthroplasty surgery. The routine use of prophylactic antibiotics has
not been shown to be effective in selected elective soft tissue procedures. No benefit has
been shown in extending courses of prophylactic antibiotics beyond 24 hours in Elective
Orthopaedic Arthroplasty surgery.
Antibiotic Choice / Spectrum of Activity
a) The antibiotic used for prophylaxis should have a spectrum of activity against the likely
infective organisms (primarily skin organisms, aerobic gram-positive cocci), have high
tissue concentrations at the time of incision and be relatively inexpensive.
b) Regional resistance patterns and patient allergies must be taken into account.
Routine elective prophylaxis Cefazolin
β-lactam allergy Clindamycin
Known MRSA Clindamycin (if susceptible to erythromycin), or
Vancomycin
Timing
a) Timing and dosage should optimise efficiency of therapy.
b) Antibiotics should be administered within 60 minutes, and at least 5 minutes from start, of
surgical incision to optimise tissue levels at time of surgery.
c) No benefit has been shown to antibiotics administered after surgical start time, with an
increase in SSI in patients in whom antibiotic prophylaxis is commenced >6 hours after
surgery.
d) Vancomycin infusions should begin within 2 hours of surgical incision due to extended
infusion times.
e) Antibiotics should be completely administered 5 minutes prior to inflation of a tourniquet.
f) For prolonged procedures, or following significant blood loss, additional doses of
prophylactic antibiotics are recommended.
Cefazolin (all adults 2 g IV with induction of anaesthesia
all weights) Repeat every 2 - 5 hours intra-operatively
Clindamycin 600 mg IV with induction of anaesthesia
Repeat 3 - 6 hours intra-operatively
Vancomycin 1 g IV over 1-2 hours (maximum rate of 10 mg / minute) in
patients up to 70kg, then 15mg/kg to a maximum of 2g in
patients weighing more than 70kg
Infusion to start at least 60 minutes prior to induction of
anaesthesia with the infusion to be completed prior to incision
Repeat 6 - 12 hours intra-operatively
Duration of prophylactic Antibiotics
a) Duration of antibiotic prophylaxis should not exceed 24 hours postoperatively for
Orthopaedic Arthroplasty surgery and may contribute to the development of resistance.
b) A single preoperative dose of prophylactic antibiotics only is required for complex
arthroscopic procedures involving implants.

Issue Date: Sep 2017 Page 1 of 3 NOTE: The electronic version of

Review Date: Sep 2018 Version No: 4 this document is the most current.
Protocol Steward: Infectious Authorised by: Medical Director Any printed copy cannot be
assumed to be the current version.
Diseases Physician
 ANTIBIOTICS AND ANTIMICROBIALS –
Policy 4.1.11
ORTHOPAEDIC SURGERY – RECOMMENDATIONS
ANTIBIOTICS & Protocol 4
FOR PRE-OPERATIVE ANTIBIOTIC PROPHYLAXIS
ANTIMICROBIALS
PROTOCOL

SUMMARY
Elective Orthopaedic Surgery

Elective Joint Replacement Surgery

Preoperative Postoperative
Routine Cefazolin 2g IV Cefazolin 2g IV q8h
3 postoperative doses
β-lactam allergy Clindamycin 600 mg Clindamycin 600 mg IV q8h
IV 2 postoperative doses
(or preferably 450 mg q6h if
able to take orally)
MRSA colonised Clindamycin as above
if MRSA susceptible to
erythromycin / clinda
Vancomycin <70kg 1 g 1 post-operative IV dose 12
IV >70kg 15mg/kg IV hours after pre-operative dose.
over 1-2 hours
Shoulder replacement Cefazolin plus
clindamycin as above
Note: Routine use of antibiotic-loaded PMMA cement
Preoperative clipping (not shaving) of surgical site (to be done in SAU / ward)

Elective Non-Arthroplasty Surgery

Preoperative Postoperative
Spine surgery Single dose of preoperative IV Cefazolin as per above
Simple arthroscopic Not required
procedures
Complex arthroscopic Single preoperative Not required
procedures (e.g. requiring dose
implants, prolonged)
Hand simple soft tissue Not required
surgery (CTR, Dupuytren’s
release)
Hand surgery reconstruction / Single preoperative Not required
arthroplasty / prolonged dose
Simple soft tissue procedures Not required
Complex soft tissue Single preoperative Not required
procedures dose

Acute Orthopaedic Surgery

Preoperative Postoperative
Arthroplasty Surgery As for Elective Joint Replacement Surgery
Closed fracture fixation Single preoperative Not required

Issue Date: Sep 2017 Page 2 of 3 NOTE: The electronic version of

Review Date: Sep 2018 Version No: 4 this document is the most current.
Protocol Steward: Infectious Authorised by: Medical Director Any printed copy cannot be
assumed to be the current version.
Diseases Physician
 ANTIBIOTICS AND ANTIMICROBIALS –
Policy 4.1.11
ORTHOPAEDIC SURGERY – RECOMMENDATIONS
ANTIBIOTICS & Protocol 4
FOR PRE-OPERATIVE ANTIBIOTIC PROPHYLAXIS
ANTIMICROBIALS
PROTOCOL

dose prophylactic
antibiotics
Open fractures
 The management of open fractures is different from Elective Orthopaedic Surgery.
 Treatment with antibiotics is required at the time of hospital presentation with
appropriate wound management and assessment of tetanus immunisation status.
 Treatment should be continued until 72 hours after definitive wound closure for wounds
of Grade 2 and over and then the need for antibiotics reassessed.
Grade 1 injuries As for Elective Orthopaedic Surgery
Grade 2 injuries Add gram negative
cover (gentamicin)
Grade 3 injuries Add gram negative and
(extensive soft tissue injury, anaerobic cover
gross contamination, (gentamicin and
associated vascular injury metronidazole)
Note: Routine use of antibiotic-loaded PMMA cement
Preoperative clipping (not shaving) of surgical site
 Gentamicin should be used at a 5 - 7 mg / kg once daily dose using Ideal Body Weight
(IBW) adjusted to 3 mg / kg (IBW) in the case of renal impairment (maximum dose of
400mg) - patients requiring ongoing doses must be discussed with the Infectious
Diseases (ID) team. See protocol MED.G3.1 Gentamicin Dosing for full details.
 Where the patient is able to take treatment orally, post-operative doses of metronidazole
can be given orally.

ASSOCIATED DOCUMENTS
 Bay of Plenty District Health Board policy 4.1.11 Antibiotics and Antimicrobials
 Bay of Plenty District Health Board policy 4.1.11 protocol 1 Antibiotics and Antimicrobials
- Restricted Antimicrobial List
 Bay of Plenty District Health Board policy 4.1.11 protocol 2 Antibiotics and Antimicrobials
- Antibiotic Recommendations for Common Conditions in Adults
 Bay of Plenty District Health Board policy 4.1.11 protocol 5 Antibiotics and Antimicrobials
- General Surgery - Recommendations for Pre-operative Antibiotic Prophylaxis
 Bay of Plenty District Health Board policy 4.1.11 protocol 6 Antibiotics and Antimicrobials
- Surgical Specialties - Recommendations for Pre-operative Antibiotic Prophylaxis
 Bay of Plenty District Health Board Medications protocol MED.G3.1 Gentamicin
 Bay of Plenty District Health Board Medications protocol MED.V5.1 Vancomycin (IV and
Oral)
 Bay of Plenty District Health Board policy 4.1.0 Infection Control Management

Issue Date: Sep 2017 Page 3 of 3 NOTE: The electronic version of

Review Date: Sep 2018 Version No: 4 this document is the most current.
Protocol Steward: Infectious Authorised by: Medical Director Any printed copy cannot be
assumed to be the current version.
Diseases Physician